Volume 04 · Issue 04 · 2018

The transcription factor Homeobox C8 (HOXC8) is overexpressed and regulates many important genes involved in the proliferation and invasion of many malignant tumors. However, the function of HOXC8 in gliomas remains unclear.

Based on the Chinese Glioma Genome Atlas (CGGA) set, HOXC8 expression is negatively correlated with overall survival (OS). Small interfering RNA (si-HOXC8) was used to downregulate the mRNA and protein expression levels of HOXC8 to assess glioma cell proliferation, migration and invasion.

Patients with higher HOXC8 levels showed poorer prognosis. DAVID analysis results indicated that HOXC8 was related to cell cycle, cell adhesion and immune response. In U251 and LN229 glioma cells treated with small interfering RNA for HOXC8 (si-HOXC8) for gene knockdown, significantly lower cell capacity of growth, migration and invasion was observed. Moreover, HOXC8 knockdown could reduce the protein expression of classical epithelial mesenchymal transition (EMT) related markers.

HOXC8 may play an important role in glioma proliferation, migration and invasion. These findings indicated that HOXC8 may constitute a novel target for glioma treatment.

Inhibition of CD4 T cells reduces stroke-induced infarction by inhibiting neuroinflammation in the ischemic brain in experimental stroke. Nevertheless, little is known about its effects on neuronal survival signaling pathways. In this study, we investigated the effects of CD4 T cell deficits on oxidative stress and on the Akt/mTOR cell signaling pathways after ischemic stroke in mice.

MHC II gene knockout C57/BL6 mice, with significantly decreased CD4 T cells, were used. Stroke was induced by 60-min middle cerebral artery (MCA) occlusion. Ischemic brain tissues were harvested for Western blotting.

The impairment of CD4 T cell production resulted in smaller infarction. The Western blot results showed that iNOS protein levels robustly increased at 5 h and 24 h and then returned toward baseline at 48 h in wild-type mice after stroke, and gene KO inhibited iNOS at 5 h and 24 h. In contrast, the anti-inflammatory marker, arginase I, was found increased after stroke in WT mice, which was further enhanced in the KO mice. In addition, stroke resulted in increased phosphorylated PTEN, Akt, PRAS40, P70S6, and S6 protein levels in WT mice, which were further enhanced in the animals whose CD4 T cells were impaired.

The impairment of CD4 T cell products prevents ischemic brain injury, inhibits inflammatory signals, and enhances the Akt/mTOR cell survival signaling pathways.

Most adult trauma protocols suggest that where there has been a dangerous mechanism of injury or the patient exhibits abnormal physiology, CT scan is the primary radiological investigation. Other patients who may have suffered thoraco-lumbar (T-L) trauma initially have antero-posterior (AP) and lateral plain X-rays performed. Our clinical experience suggests AP views are not particularly useful in the management of these relatively low-velocity injuries. This is the first study intended to determine the contribution made by AP X-rays in these cases.

Adults with a history of T-L trauma referred to our tertiary spinal service over 20 weeks were reviewed. Those with a CT scan performed prior to X-rays were excluded. Four spine surgeons and four neuroradiologists were independently shown lateral X-rays along with the clinical details and asked to provide a management plan. Then they were shown the AP X-rays and asked if they would like to change their advice.

Fifty-two patients were identified. Thirty-four sets of supine and 40 sets of erect X-rays were included (four people only had lateral X-rays performed), yielding 1152 film views. Average patient age was 58.3 years with 30 (58%) males. Forty-five (87%) were AO type A (compression-type) fractures. Seven (13%) had been erroneously referred with a diagnosis of acute fracture, which on review was not considered to be the case. Fifty-four percent of fractures were between T11 and L2. Forty-six percent appeared osteoporotic.

In no instance did evaluation of the AP X-ray change the management plan which had been suggested following the evaluation of the lateral X-ray alone. However, there was significant variation in advice on further management between consultants.

Our results suggest AP X-rays do not contribute to the management of low-velocity thoraco-lumbar traumas. Larger studies are required to support these findings, but there appears to be a potential to reduce both cost and radiation exposure. More importantly, it demonstrates there is large variability in the management of such patients due to the lack of evidence-based protocols.

Although coagulopathy have been proved to be a contributor to a poor outcome of aneurysmal subarachnoid hemorrhage (aSAH), the risk factors for triggering coagulation abnormalities have not been studied after aneurysm clipping.

We investigated risk factors of coagulopathy and analyzed the relationship between acute coagulopathy and outcome after aneurysm clipping. The clinical data of 137 patients with ruptured CA admitted to our institution was collected and retrospectively reviewed. Patient demographic data (age, sex), smoking, alcohol use, hypertension, diabetes, Hunt-Hess grade, Fisher grade, operation time, intraoperative total infusion volume, intraoperative blood loss, intraoperative transfusion, intraoperative hemostatic drug treatment, calcium reduction (preoperative free calcium concentration–postoperative free calcium concentration) were recorded. Coagulation was assessed within 24 h. Postoperative hemorrhage and infarction, deep venous thrombosis (DVT), and mortality were analyzed.

Coagulopathy was detected in a total of 51 cases (group I), while not in 86 cases (group II). Univariable analysis demonstrated that age, smoking, alcohol use, intraoperative total infusion volume, intraoperative blood loss, intraoperative transfusion, and calcium reduction (≥ 1.2 mg/dl) were related to coagulopathy. Non-conditional logistic regression analysis showed that age [OR, 1.037 (95% CI, 1.001–1.074); p = 0.045] and calcium reduction (≥ 1.2 mg/dl) [OR, 5.509 (95% CI, 1.900–15.971); p = 0.002] were considered as the risk factors for coagulopathy. Hunt-Hess grade [OR, 2.641 (95% CI, 1.079–6.331); p = 0.033] and operation time [OR, 0.107 (95% CI, 1.012–0.928); p = 0.043] were considered as the risk factors for hypocoagulopathy. There were 6 cases (11.7%) with cerebral infarction in group I, while 6 cases (6.98%) in group II (χ² = 0.918, p = 0.338). There were 4 cases (7.84%) with rebleeding in group I, while 5 cases (5.81%) in group II (χ² = 0.215, p = 0.643). The mortality was 9.80% (5/51) in group I, while 1.16% (1/86) in group II (χ² = 5.708, p = 0.017). DVT was not detected in all cases.

In conclusion, age (≥ 65 years) and calcium reduction (≥ 1.2 mg/dl) were considered as the risk factors for coagulopathy and have been proved to be associated with higher mortality after aneurysm clipping.

Pipeline embolization device (PED) has proved its safety and efficacy in the treatment of intracranial large and giant side-wall aneurysms. With the accumulation of treatment experience, it is an inevitable trend to expand its off-label use on aneurysms. Whether flow diversion is safe and efficient in cases with special angioarchitecture has rarely been explored.

We performed a retrospective analysis of 210 consecutive patients treated by PED for intracerebral aneurysms in our center. Except for aneurysm, those patients also presented with special angioarchitecture: Fetal PCA, AVM, V-B junction and DAVF.

Nine patients were qualified for the study. 1 was with fetal PCA, the aneurysm remained patent on 4-month follow-up. 2 with ipsilateral AVMs, one patient died due to brain hemorrhage 20 days after the operation, the other one was only partially embolised on 6 month follow up. 3 aneurysms located at V-B junction, angiographic follow up on 3 months demonstrated no complete occlusion of both the aneurysms, the other patients were still on follow up. All of the 3 cases with concomitant DAVF are completely occluded during short to midterm follow up.

PED for aneurysms incorporated the fetal PCA and V-B junction might meet a high propensity for incomplete occlusion during short term follow up. Aneurysm with ipsilateral AVM is not suitable for PED treatment due to the risk of hemorrhage and incomplete occlusion during midterm follow up. For aneurysm with concurrent DAVF, PED treatment is safe and efficient relatively in one session or by staged operation.

Until recently, tumors of the clivus and the anterior region of the posterior cranial fossa were considered extremely difficult to access and often inoperable using standard transcranial approaches. With the introduction into the neurosurgical practice of minimally invasive methods utilizing endoscopic techniques, it became possible to effectively remove hard-to-reach tumors, including central tumors of the anterior region of the posterior cranial fossa.

From 2008 to the present time, the inpatient institution has operated on 140 patients with various tumors of the base of the skull, localized to the clivus and anterior region of the posterior cranial fossa (65 men and 75 women). The age of patients ranged from 3 to 74 years. Tumor distribution according to the histopathological features was as follows: chordomas, 103 (73.57%); meningiomas, 12 (8.57%); pituitary adenomas, 9 (6.43%); fibrous dysplasia, 4 (2.86%); cholesteatoma, 3 (2.14%); craniopharyngiomas, 2 (1.43%); plasmacytomas, 2 (1.43%); and other tumors (giant cell tumor, neurohypophyseal glioma, osteoma, carcinoid, chondroma), 5 (3.57%). The tumors had the following size distribution: giant (more than 60 mm), 35 (25%); large (35–59 mm), 83 (59.3%); medium (21–35 mm), 21 (15%); and small (less than 20 mm), 1 (0.7%). In 11 cases, intraoperative monitoring of the cranial nerves was performed (21 cranial nerves were identified).

Upper, middle, and lower transclival approaches provide access to the anterior surface of the upper, middle, and lower neurovascular complexes of the posterior cranial fossa. The chordoma cases were distributed as follows according to extent of removal: total removal, 68 (66.02%); subtotal removal, 25 (24.27%); and partial removal, 10 (9.71%). The adenomas of the pituitary gland were removed totally in 6 cases, subtotally in 1 case and partially in 2 cases. The meningiomas were removed totally in 1 case, subtotally in 5 cases, and partially in 5 cases, with less than 50% of the tumor removed in 1 case. Other tumors (cholesteatoma, craniopharyngioma, fibrous dysplasia, giant cell tumor, glioma of the neurohypophysis, osteoma, plasmacytoma, carcinoid, and chondroma) were removed totally in 9 cases and subtotally in 7 cases. Postoperative CSF leaks occurred in 9 cases (6.43%) and meningitis in 13 cases (9.29%). Oculomotor disorders developed in 19 patients (13.57%), 12 of which regressed during the period from 4 to 38 days after surgery, and 7 of which were permanent. In 2 cases, surgical treatment had a lethal outcome (1.43%).

The endoscopic endonasal transclival approach can be used to obtain access to the centrally located tumors of the posterior cranial fossa. It is an alternative to transcranial approaches in the surgical treatment of tumors of the clivus. The results of using this approach are comparable with the results of transcranial and transfacial approaches and, in some cases, surpass them in effectiveness. The extended endoscopic endonasal posterior (transclival) approach, considering its minimally invasive nature, allows fora radical and low-risk (in terms of postoperative complications and lethality) removal of various skull base tumors of central localization with the involvement and without the involvement of the clivus, which, until recently, were considered to be almost inoperable.

In the past, the cavernous dural arteriovenous fistula was categorized as spontaneous cavernous carotid fistula [1] due to the lack of knowledge and limitation of imaging equipment. In the recent time, with the accumulation of knowledge of DAVF’s etiology, mechanism, physiology, clinical symptoms and imaging data, the diagnostic methods and treatment have achieved novel understandings and progresses. In fact, it’s a specific type of dural arteriovenous fistula—— cavernous dural arteriovenous fistula. The purpose of this paper is to tell the difference between cavernous dural arteriovenous fistula and traumatic carotid cavernous fistula, and to redefine cavernous dural arteriovenous fistula from the aspects of etiology, mechanism, pathology, clinical symptoms, DSA characteristic and therapy. DAVF is an independent disease. The Cavernous dural arteriovenous fistula can not be classified as spontaneous CCF any longer, but a specific type of DAVF— cavernous DAVF.

Primary intraventricular hemorrhage is an uncommon cause of stroke and is often associated with longstanding, uncontrolled hypertension. Reversible cerebral vasoconstriction is also an uncommon condition characterized by reversible constriction of intracerebral vessels, which can lead to ischemic or hemorrhagic strokes.

We describe a case of isolated primary intraventricular hemorrhage secondary to reversible cerebral vasoconstriction syndrome triggered by pseudoephedrine.

Reversible cerebral vasoconstriction syndrome is a rare cause of primary intraventricular hemorrhage and should be considered in the differential in angiography-negative IVH when there is a history of vasoactive substance use.

A rare case of cerebral abscess concurrent with pulmonary arteriovenous fistula (PAVF), hyperhemoglobinemia, and hypoxemia was reported.

A 37-year-old man was admitted with a headache, nausea, vomiting, fever, and numbness of the left cheek and upper limb for 10 days. Cerebral magnetic resonance imaging (MRI) shows the lesion in his right frontal lobe. Blood gas analysis indicated lower blood oxygen saturation level, and blood routine test showed hemoglobin elevation. Craniotomy for the lesion and decompressive craniotomy were performed. Brain abscess was confirmed by pathology examination. The chest computed tomography angiography (CTA) revealed a pulmonary arteriovenous fistula (PAVF) in his right lower lung. After 1 month, embolization of PAVF was performed. Anoxic symptom improved after surgery. Cranioplasty was performed after 7 months.

The author reported a rare case of cerebral abscess associated with pulmonary arteriovenous fistula. Brain abscess, hyperhemoglobinemia, and hypoxemia might be secondary to PAVF. Treatment of patients includes not only craniotomy for abscess removal but also embolization of PAVF which can prevent recurrence of brain abscess.